Fuller v. Sun Life Assurance Co. of Can.

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THOMAS FULLER, Plaintiff, v. SUN LIFE ASSURANCE COMPANY OF CANADA, Defendant.

CIVIL No. 1:23cv1241 (DJN)

United States District Court, E.D. Virginia, Alexandria Division

September 6, 2024

MEMORANDUM OPINION

David J. Novak United States District Judge

This matter comes before the Court following a multiyear dispute over Plaintiff Thomas Fuller's eligibility for long-term disability benefits. Defendant Sun Life Assurance Company of Canada distributed Fuller's disability benefits for twenty-four months, but on August 12,2022, Sun Life concluded that Fuller no longer suffered an ongoing disability as defined by his benefits plan. After a year-long dispute that involved a half dozen physicians, dueling interpretations of those physicians' opinions, and Sun Life's final administrative denial of Fuller's claims, this civil action followed. The parties now move for final adjudication of their dispute. (ECF Nos. 36, 38). For the reasons that follow, the Court will GRANT Sun Life Judgment on the Administrative Record and DENY Fuller Judgment on the Administrative Record.

I. BACKGROUND

Thomas Fuller is a fifty-five-year-old former employee of EMCOR Group, Inc., a Connecticut-based construction company. (Administrative Record (“AR”) (ECF No. 23) at ARI50-52). As an EMCOR employee, Fuller was covered by its Employee Welfare Plan (“EWP” or the “Policy”), which was established under the Employee Retirement Income Security Act of 1974 (“ERISA”). (Complaint (ECF No. 1) at ¶¶ 4-5). Sun Life insured a subcomponent of the EWP, EMCOR's Long-Term Disability (“LTD”) Income Insurance, and EMCOR designated Sun Life as a fiduciary of the Policy and claims review administrator. (ARI 14). As claims review administrator, Sun Life wields “authority to make all final determinations” as to “eligibility for benefits,” “the amount of any benefits due” and interpretation of “the terms of th[e] Policy.” (AR144-45 (EWP § VII.B).

Fuller worked as a General Foreman for EMCOR, where his primary responsibilities involved supervising work crews. (ARI 50). The position “involve[d] a lot of walking” between and through construction sites and required the capacity to “lift heavy cabling and ladders.” (ARI 13, ARI51). On May 5,2020, Fuller slipped on wet floor tiles in his kitchen and fell reeling to the ground. (AR445 AR534). His lumbar spine absorbed the shock of the impact and by May 12, Dr. Deeni Bassam of the Spine Care Center - a treatment facility for back and neck injuries - diagnosed Fuller with a collapsed lumbar vertebra. (AR533-35). Approximately two months after his injury, Fuller underwent kyphoplasty to alleviate his pain.^[1](ARI 93). That treatment proved unsuccessful, and Fuller spent the next year and a half in physical therapy on Dr. Bassam's recommendation. (ARI94-95; AR445). During that time, Fuller tried “epidurals, cortisone injections, and a nerve abla[t]ion” to assuage his discomfort, but to no avail. (Id.) Debilitating pain continued to radiate down Fuller's back, and Dr. Aijun Ramesh, also of the Spine Care Center, diagnosed Fuller with lumbar radiculopathy. (AR345).

Dr. Ramesh took over Fuller's treatment and recommended that he undergo lumbar interlaminar epidural steroid injections, which Dr. Ramesh administered across April and May 2022^[2] (AR316-321). Fuller received some respite from this treatment - following his last injection, he experienced “100% sustained relief' - but that relief abated over time. (Id.; see also AR330 (reporting initial success followed by a return of symptoms after earlier treatments)). By June 30,2022, Fuller's pain had returned in full force, and Dr. Ramesh added complex regional pain syndrome (“CRPS”) to Fuller's list of diagnoses. (AR329-30).

Meanwhile, Fuller's injuries rendered him unable to continue as a Foreman. He applied for LTD benefits, and Sim Life approved that application on May 14,2020. (AR214). Under the terms of the EWP, an employee is disabled if he “is unable to perform the Material and Substantial Duties of his Own Occupation” “because of Injury or Sickness.”^[3] (ARI 24). But that definition of “disability” governs only for an employee's first 24 months of disability payments. After that point, employees stand subject to a stricter definition, which requires that an employee be “unable to perform with reasonably continuity any Gainful Occupation for which he is or becomes reasonably qualified” to remain eligible for benefits. (ARI24-25). Fuller first received LTD benefits on August 12,2020, rendering his final day under the laxer disability standard as August 11, 2022. (AR214).

On December 6,2021, Sun Life informed Fuller that the stricter eligibility standard would soon apply, and it described the information necessary to sustain LTD benefits. (AR218-19). In anticipation of this change, on January 31, 2022, Sun Life prepared a Transferable Skills Analysis (“TSA”) to identify alternate employment opportunities for Fuller. (AR245-48). The TSA identified two occupations that Sun Life believed offered Fuller gainful employment commensurate with his experience, prior compensation and physical condition.^[4] (Id.) The TSA based its conclusion on a medical review conducted nine months prior by a Sun Life consultant, Dr. Scott Strum. (Id; see ARI52-57 (Dr. Strum's report)). Fuller was not contacted during this process. (AR245).

On June 2, 2022, Dr. Ramesh certified Fuller to return to work on permanent light duty status, subject to several physical limitations. (AR307-10). Fuller adamantly disagreed with that assessment, so he called Sun Life to explain why his various handicaps prevented him from working. (AR322-24). Dr. Ramesh agreed that Fuller's mobility was severely limited: in Dr. Ramesh's judgment, as of July 12, Fuller could stand for no more than five minutes and sit for no more than one hour continuously, and stand for less than two hours and sit for about two hours in an eight-hour workday. (AR345-48 (the “July 12 Statement”)). Nevertheless, Dr. Ramesh concluded that Fuller could return to work. (AR331-334).

Sun Life sent Fuller's records to Dr. William Barreto, a physician with the National Medical Evaluation Services, for an independent review. (AR386-90). On August 26, 2022, Dr. Barreto opined that Fuller could return to full-time work subject to the limitations articulated by Dr. Ramesh. (Id.) Dr. Barreto based his judgment exclusively on a review of the cold record; Dr. Baretto did not contact Fuller, and he did not consult with Dr. Ramesh, as Dr. Ramesh's staff ostensibly claimed that he would not conduct a telephonic peer-to-peer review.^[5] (Id.) On August 31, relying on Dr. Baretto's findings, Sun Life issued another TSA. That second TSA adhered to Sun Life's prior conclusions and identified three occupations where Fuller could be gainfully employed. (AR394-95). Armed with Dr. Barreto's report and the updated TSA, Sun Life notified Fuller on September 12 that, as of August 12, 2022, he no longer satisfied the LTD criteria. (AR396-400).

Fuller appealed Sun Life's denial of coverage by a letter dated February 26,2023. (AR581-86). In his appeal, Fuller asserted that Sun Life failed to account for Dr. Ramesh's July 12 Statement, disputed that Dr. Ramesh was unwilling to consult with Dr. Barreto, and explained that his enervating pain rendered him “unable to perform the[] tasks” that Sun Life found him competent to perform. (Id.) To assuage these concerns, Sun Life inaugurated a second independent review of Fuller's file, which was completed by Dr. Arlen Green on April 18, 2023. (AR406-11). This review broke no new ground. Dr. Green judged that there was “no evidence” that Fuller was “incapable of performing full-time sedentary work activities [as of] August 12, 2022.” (Id.)

Dr. Green's findings prompted Fuller to retain counsel. (AR643-44). Through counsel, Fuller pressed for additional time to refute Dr. Green's findings, and on August 1, 2023, Fuller supplemented his appeal with a new tranche of documents, including a September 20,2020, report from Dr. Sohail Mirza (AR537-43); a June 28,2023 Functional Capacity Evaluation (“FCE”) (AR443-55); and a spate of additional records from Dr. Ramesh. (AR460-535). In response, Sun Life commenced a third - and final - independent medical review. The same result obtained. On August 16,2023, Dr. Andrew Nava, like Dr. Baretto and Dr. Green before him, concluded that Fuller was “[] capable of performing full-time ... sedentary [w]ork.” (AR545, AR547). Sun Life compiled an addendum to its TSA from the prior year, pointing out the same three occupations as it had in August 2022. (ARI201-02).

Fuller, through counsel, wrote Sun Life on August 30 to express his “disappoint[ment] and concem[]” regarding Sun Life's use of Dr. Nava's report, which Fuller believed was “deficient,” because Dr. Nava failed to review Dr. Ramesh's July 12 Statement and “misinterpret[ed]” the results of Fuller's FCE, and because, in Fuller's view, Dr. Nava's competence was suspect. (AR557-60). Fuller stridently flagged Dr. Nava's “shady track record” and “incompetence,” as evinced by a compendium of negative online patient reviews. (Id.) The letter concluded with a series of questions that Fuller demanded Sun Life answer within the next approximately two weeks. (AR564-65). Sun Life required only two days. On September 1, 2023, Sun Life delivered its final denial of Fuller's LTD benefits. (ARI 209-1220).

Thirteen days later, on September 14, 2023, Fuller sued. (Complaint (ECF No. 1)). Four rounds of briefing followed. First, at the parties' request, the Court directed an initial round of briefing on the applicable standard of review. (ECF Nos 13,14). The parties then filed cross motions for summary judgment (ECF No. 26) and judgment on the...